Bowel cancer – 40 years of progress but early detection is key

Spotting cancer early can save lives. Over the last nine weeks, the Department of Health has been running a campaign called ‘Be Clear on Cancer’, aimed at raising awareness of bowel cancer symptoms.

The campaign ended over the weekend, but keeping the focus on the disease, today marks the start of Bowel Cancer Awareness Month.

So we thought it would be a good idea to look at how things have changed for bowel cancer patients over the years, and how continued research has lead to a falling mortality rate.

In the graphic below, you can see how this improvement has been driven by research on bowel cancer, both by our own researchers and by scientists around the world. And you can scroll down to read about this research in more detail.

Setting the scene

About 40 years ago, people with bowel cancer were typically operated on to remove their tumour, and surgery is still the mainstay of treatment today. But back then, little was known about how best to use chemotherapy (nor, for that matter, radiotherapy).

During the the 1960s and 70s, research began to suggest that a chemotherapy drug called 5-fluorouracil, or 5-FU (first discovered in 1957), had significant potential to improve things. As we’ll see below, refining how best to use this drug, and who to give it to, has been one of the key things that’s improved bowel cancer mortality rates.

1980s

In 1982, researchers first described how to carry out a new surgery technique called ‘total mesenteric excision’, or TME, for rectal cancer. This became more widely used over the years, and a follow-up study showed that it was better at preventing the disease from coming back, and improved survival rates.

In 1986, a US trial showed that patients with rectal cancer benefited from having radiotherapy alongside chemotherapy.

In 1987 Cancer Research UK scientists pinpointed the APC bowel cancer gene. Kat’s post about this is well worth a read, as this was a landmark in understanding the disease’s inner workings, and ultimately allowed affected families to be offered genetic testing and preventative screening.

Another significant step forward in the 80s was the confirmation that a drug called folinic acid improved the effectiveness of 5-FU.

1990s

Several more steps forward were taken in the 1990s. Firstly, keyhole surgery began to emerge as a better way to treat cancer. It took a while for this to become standard practice (NICE recommended it in 2006), and the NHS is currently rolling out a training programme to make sure this is widely available. Research in 2009 confirmed that availability was on the up.

Also in the 1990s, researchers really began to nail down how best to use 5-FU. For example, giving people with incurable bowel cancer 5-FU after surgery was shown to improve long-term survival rates, and other studies showed that it could cure people with less advanced cancer that was at high risk of spreading.

Two large studies began – the EPIC study of diet and cancer started recruiting in 1992, and a large bowel screening study in 1994 began to investigate a technique called flexible sigmoidoscopy (flexi-sig). Cancer Research UK helped fund both studies.

More progress was made in understanding bowel cancer’s genetics. For example, in 1995 our researchers in Cambridge published a paper on an inherited bowel cancer syndrome called Hereditary Non-Polyposis Colon Cancer, or HNPCC (also known as Lynch Syndrome). This led to more people being offered genetic testing and screening.

In 1998 he Committee on Medical Aspects of Food and Nutrition Policy (COMA) publisheda landmark report. It ruled that the evidence linking red and processed meat to a higher risk of bowel cancer was strong enough to recommend people limit their consumption.

And two significant policy changes were brought in by the UK government. Firstly, in 1997 the Department of Health recommended that patients should be treated by teams of medics from different areas of expertise – so-called multidisciplinary teams. And in 1999, the Government introduced the ‘Two week wait’ for suspected cancer patients which undoubtedly helped people be seen more quickly and likely saved lives.

2000s

In 2003, the EPIC study showed that a high-fibre diet could reduce the risk of developing the disease, giving people more information about choices they could make to stack the odds in their favour.

And by 2005, surgery to remove liver and lung metastases had become standard for suitable patients. This led to even more people being cured.

After intense pressure from Cancer Research UK and our colleagues in other organisations, a national bowel screening programme began rolling out in 2006, based on the fecal occult blood test (which detects blood in your stools).

And the landmark Cancer Research UK-funded QUASAR trial proved in 2007 that 5-FU chemotherapy could benefit many more bowel cancer patients. Previously the drug had only been offered to people whose cancer seemed likely to spread after surgery. QUASAR showed that its benefits extended to ‘medium risk’ disease.

2010s

In March 2010, we were delighted to hear that the Flexi-sig screening trial had shown that this technique could save more lives. We pushed the Government to include it in the screening programme, and they agreed later that same year. We now need to make sure this is implemented across the UK as soon as possible.

And last year, the Cancer Research UK-funded CAPP2 trial showed that people with HNPCC (Lynch Syndrome) would benefit from taking aspirin to reduce their risk.

What’s in the pipeline?

Looking to the future, several things give us reason to believe that the downward trend in bowel cancer deaths will continue.

There’s still some debate over how best to use these drugs (which are expensive) but some of them are now available for use under certain circumstances. We’re running trials like FOCUS2, PICCOLO and COIN to try to find out how to get the most bang for their considerable buck, and to assess whether they’re suitable for wider use.

But many of these drugs work best in people whose cancer has certain gene changes. Another big thing on the horizon is routine genetic testing on the NHS, as part of ‘stratifying’ patients into groups. We’re leading the charge on this with our Stratified Medicines programme.

Finally, we’re just starting to see the effects of the bowel screening programme, and this will continue over the next decade, particularly as flexi-sig starts to impact on the programme. Screening can be controversial, so we need to keep an eye on the programme to make sure it’s as effective as it can be.

Get checked out

More and more people are surviving bowel cancer, as researchers translate their findings into better treatment.

So here’s our key message: if you notice any of the disease’s symptoms, PLEASE get yourself checked out by a GP.

The key symptoms include blood in your stools, looser stools or bleeding from your bottom, for longer than 3 weeks.

But they also include other, vaguer things like bloating, abdominal pain and unexplained weight loss. The chances are it won’t be cancer, but if it is, getting an earlier diagnosis can make a real difference – and it’s better to find out than ignore the warning signs.

If more bowel cancers are diagnosed at an early stage, thousands of lives in this country could be saved. Better treatments are on the way, but – as we never tire of saying – they’re almost always more effective when we spot cancer early.

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